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FISCAL ACCOUNTABILITY AND PERFORMANCE
INSURANCE PRE-CERTIFICATION PROCESS
Information: June Cowen
Project Goals
Determine opportunities to reduce the number of denials associated with the rise of insurance companies requiring ordering physicians to contact third party clearing houses for approval of non-emergent, outpatient, advanced imaging procedures.
The Pre-Cert Team was comprised of a Massachusetts General Physician Organization (MGPO) Billing Manager and Radiology Service Representatives/Pre-Cert Coordinators. QME facilitated the needs assessment gathering process to meet the various insurer requirements. Failure points were identified; solutions were presented and shared.
Results
- New process improvements implemented
- Rejections and denials are on significant downward trend
Next Steps
- Continue to monitor and document the processes
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